future of patient safety and healthcare qualitycenter for medicare and medicaid innovation •...
TRANSCRIPT
Future of Patient Safety and Healthcare Quality
Patrick Conway, M.D., MScCMS Chief Medical Officer
Director, Center for Clinical Standards and Quality
Acting Director, Center for Medicare and Medicaid Innovation
Sept. 20, 2013
Discussion
• Our Goals and Early Results• Value-based purchasing and quality improvement
programs• Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement• Future and Opportunities for collaboration
Size and Scope of CMS Responsibilities
• CMS is the largest purchaser of health care in the world (approx
$900B per year)
• Combined, Medicare and Medicaid pay approximately one-third of national health expenditures.
• CMS programs currently provide health care coverage to roughly 105
million beneficiaries in Medicare, Medicaid and CHIP (Children’s Health Insurance Program); or roughly 1 in every 3 Americans.
• The Medicare program alone pays out over $1.5 billion in benefit
payments per day.
• CMS answers about 75
million inquiries annually.
• Millions of consumers will receive health care coverage through new health insurance programs authorized in the Affordable Care Act.
Better Health forthe Population
Better Carefor Individuals
Lower CostThrough
Improvement
Our Aims
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How do we ensure quality care?
• Improvement as a Strategy
• Customer-Mindedness• Outcomes Focus• Statistical Thinking• Continual Improvement
(PDSA)• Leadership
How Will Change Actually Happen?
• There is no “silver bullet”• We must apply many incentives• We must show successful alternatives• We must offer intensive supports
– Help providers with the painstaking work of improvement
• We must learn how to scale and spread successful interventions
The “3T’s”
Road Map to Transforming U.S. Health Care
Key T1 activity to testwhat care works
Clinical efficacy research
Key T2 activities to testwho benefits from
promising care
Outcomes researchComparative effectiveness
Research
Health services research
Key T3 activities to testhow to deliver high-quality
care reliably and inall settings
Quality Measurement andImprovement
Implementation of Interventions and health
care system redesign
Scaling and spread of effective interventions
Research in above domainss
T1 T2 T3Basic biomedicalscience
Clinical efficacy knowledge
Clinical effectivenessknowledge
Improved healthcare quality &
value &population health
Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp. 2319-2321. The “3T’s Roadmap to Transform U.S. Health Care: The ‘How’ of High-Quality Care.”
Transformation of Health Care at the Front Line
• At least six components– Quality measurement– Aligned payment incentives– Comparative effectiveness and evidence available– Health information technology– Quality improvement collaboratives and learning
networks– Training of clinicians and multi-disciplinary teams
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Source: P.H. Conway and Clancy C. Transformation of Health Care at the Front Line. JAMA 2009 Feb 18; 301(7): 763-5
Early Example Results
• Cost growth leveling off -
actuaries and multiple studies
indicated partially due to “delivery system changes”
• But cost and quality still variable
• Moving the needle on some national metrics, e.g.,
– Readmissions
– Line Infections
• Increasing value-based payment and accountable care models
• Expanding coverage with insurance marketplaces gearing up for 2014
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Results: Medicare Per-Capita Spending Growth at Historic Low
Source: CMS Office of the Actuary, Midsession Review – FY 2013 Budget
Wide Variation in Spending Across the Country
CT Scans Per Capita Spending* (2011)
Fort Myers, FL$117 per
capita
Honolulu, HI$49 per capita
National Average
= $76
Ratio to the national average
*includes institutional and professional spending
Wide Variation in Spending Across the Country
Heart Failure and Shock with Complications MS-DRG 291
Ratio to Nat’l Avg 1.49 1.15 1.00 0.85 0.71
Source: CMS Office of Information Products and Data Analysis, Medicare Claims Analysis - 2010
National Medicare 30 Day Readmissions
Quarters of participation by hospital cohorts, 2009–2012
CLABSI Rate in CUSP National Project
Over 1,000 ICUs achieved an average 41% decline in CLABSI over 6 quarters (18 months), from 1.915 to 1.133 CLABSI per 1,000 central line days.
Discussion
• Our Goals and Early Results• Value-based purchasing and quality improvement
programs• Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement• Opportunities for collaboration
The Six Goals of the CMS Quality Strategy
The Six Goals of the CMS Quality Strategy
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2
3
4
5
6
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Value-Based Purchasing
• Five Principles- Define the end goal, not the process for achieving it- All providers’ incentives must be aligned- Right measure must be developed and implemented in
rapid cycle- CMS must actively support quality improvement- Clinical community and patients must be actively
engagedVanLare JM, Conway PH. Value-Based Purchasing – National
Programs to Move from Volume to Value. NEJM July 26, 2012
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FY 2014 HVBP domains
Outcomes domain(25%)
Clinical process of care domain(45%)
Patient experience domain(30%)
• FY 15 adding efficiency domain (20%) with total cost per beneficiary for admissions; increase outcomes to 30%, decrease process to 20%
• FY16 and 17 – more outcomes weighting and safety measures, align with NQS domains
• Starting in Oct 2012, hospitals with excess risk adjusted Medicare readmissions had payments reduced (5 conditions finalized for FY15)
• Payment reductions for hospitals in bottom quartile of healthcare acquired conditions starting Oct 2014 – Finalized to start with 2 domains weighted 65/35% each:
healthcare acquired infections and healthcare acquired conditions
– Need to move beyond claims-based HAC measures over time
Other Payment adjustment programs
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• Principle of report once and receive credit for all programs: Physician Quality Reporting System, Physician Value-Based Modifier, EHR Incentive Meaningful Use, and ACO if applicable
• Focus on registry reporting and EHR based reporting, both of which can be all payer
• Group reporting growth, including for ACOs
• Physician value modifier starts in 2013 (groups of 100 or more),
proposed down to groups of 10 or more for 2014 and by 2017 adjusting all Medicare payments to physicians based on quality and cost
Physician Reporting Programs
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Discussion
• Our Goals and Early Results• Value-based purchasing and quality improvement
programs• Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement• Opportunities for collaboration
The purpose of the [Center] is to test innovative
payment and service delivery models to reduce
program expenditures…while preserving or
enhancing the quality of care furnished to
individuals under such titles.
-
The Affordable Care
Act
The CMS Innovation Center
Identify, Test, Evaluate, Scale
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Conduct many model tests to find out what works
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The Innovation Center portfolio of models will address a wide variety of patient
populations, providers, and innovative approaches to care and payment
Future State –People‐Centered
Outcomes Driven
Sustainable
Coordinated Care
Systems
New Payment
SystemsValue‐based purchasingACOs Shared SavingsEpisode‐based paymentsCare Management FeesData Transparency
Current State –Producer‐Centered
Volume Driven
Unsustainable
Fragmented Care
Systems
FFS Payment Systems
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CMMI: We need delivery system and payment transformation
The key to an improved health system A transformed mind-set by ALL
Every clinician and health care administrative person starts every day believing that success
–
whether it’s the success of the patient, the doctor, or the organization –
is directly related to their ability to achieve better outcomes and lower costs by improving care for their population and that they have
the knowledge and tools
to do it.
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Accountable Care Organizations (ACOs)
• An ACO promotes seamless coordinated care– Puts the beneficiary and family at the center– Attends carefully to care transitions– Proactively manages the beneficiary’s care– Evaluates data to improve care and patient outcomes– Innovates around better health, better care and lower
growth in costs through improvement– Invests in team-based care and workforce
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4 million Medicare beneficiaries having care coordinated by 220 SSP and 32 Pioneers ACOs
(Geographic Distribution of ACO Population)
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Quality Measurement & Performance for ACOs
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CMS Innovations Portfolio: Testing New Models to Improve Quality
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State Innovation Models
• Partner with states to develop broad-based State Health Care Innovation Plans
• Plan, Design, Test and Support of new payment and service and delivery models in the context of larger health system transformation
• Utilize the tools and policy levers available to states
• Engage a broad group of stakeholders in health system transformation
• Coordinate multiple strategies into a plan for health system improvement
• 6 Implementation states and 19 design states currently
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• Pay for a large percentage of health care services
• Can convene multiple parties • Closer to the actual delivery of care • Can regulate insurers• Can integrate state health information
exchange infrastructure and capabilities to support accountable care
• Regulate public health, social service, and educational services
States are key drivers of a transformed health system
Health Care Innovation Awards Round Two
Test new innovative service delivery and payment models that will deliver better care and lower costs for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) enrollees.• Test models in four categories:1. Reduce Medicare, Medicaid and/or CHIP expenditures in outpatient
and/or post-acute settings2. Improve care for populations with specialized needs3. Transform the financial and clinical models for specific types of
providers and suppliers4. Improve the health of populations
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Innovation Center Looking Forward
• Implementation • Monitoring & Optimization of Results• Evaluation –
Adopt, Adapt, Abandon
• Improving and Expanding CMS Capabilities
• Additional Model Tests
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Providers are Driving Transformation
• More than 50,000 providers are or will be providing care to beneficiaries as part of the Innovation Center’s current initiatives
• Millions of beneficiaries are served by Innovation Center models aimed at achieving better health outcomes at lower costs
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Comprehensive Primary Care Initiative
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State Innovation Models
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Health Care Innovation Awards
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Innovation is happening broadly across the country
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Discussion
• Our Goals and Early Results• Value-based purchasing and quality improvement
programs• Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement• Opportunities for collaboration
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CMS has a variety of quality reporting and performance programs, many led by CCSQ
CMS framework for measurement maps to the six national priorities
Greatest commonality
of measure concepts
across domains
– Measures should
be patient‐
centered and
outcome‐
oriented
whenever
possible
– Measure
concepts in each
of the six
domains that are
common across
providers and
settings can form
a core set of
measures
Person‐
and Caregiver‐
centered experience and
engagment
•CAHPS or equivalent
measures for each settings•Shared decision‐making
Efficiency and cost reduction
•Spend per beneficiary
measures•Episode cost measures•Quality to cost measures
Care coordination
•Transition of care
measures•Admission and
readmission measures•Other measures of care
coordination
Clinical quality of care
•HHS primary care and CV
quality measures•Prevention measures•Setting‐specific measures•Specialty‐specific measures
Population/ community
health
•Measures that assess health
of the community•Measures that reduce health
disparities•Access to care and
equitability measures
Safety
•Healthcare
Acquired Infections•Healthcare
acquired conditions• Harm
Quality can be measured and improved at multiple levels
•Measure concepts
should “roll up”
to align
quality improvement
objectives at all levels
•Patient‐centric,
outcomes oriented
measures preferred at all
three levels
•The six NQS domains can
be measured at each of
the three levels
Increasing
individu
al accou
ntab
ility
Increasing
com
mon
ality am
ong providers
Community
Practice setting
Individual clinician and patient
•Population‐based
denominator•Multiple ways to define
denominator, e.g., county,
HRR•Applicable to all providers
•Denominator based on practice setting,
e.g., hospital, group practice
•Denominator bound by patients cared for•Applies to all physicians•Greatest component of a physician’s total
performance
Discussion
• Our Goals and Early Results• Value-based purchasing and quality improvement
programs• Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement• Future and Opportunities for collaboration
Vision for the Future
• Measures Drive Improvement–Real-time–Local ownership with benchmarking–Linked to decision support and patient dashboards
• Measures Drive Value-Based Purchasing–Reliable–Accurate–Outcomes-based
• Measures Inform Consumers–Meaningful–Transparent
The Future of Quality Measurement for Improvement and Accountability
• Meaningful quality measures increasingly need to transition away from setting-specific, narrow snapshots
• Reorient and align measures around patient-centered outcomes that span across settings
• Measures based on patient-centered episodes of care• Capture measurement at 3 main levels (i.e., individual
clinician, group/facility, population/community)• Why do we measure?
– Improvement
Source: Conway PH, Mostashari F, Clancy C. The Future of Quality Measurement for Improvement and Accountability. JAMA 2013 June 5; Vol 309, No. 21 2215 - 2216
Opportunities and Challenges of a Lifelong Health System
• Goal of system to optimize health outcomes and lower costs over much longer time horizons
• Payers, including Medicare and Medicaid, increasingly responsible for care for longer periods of time
• Health trajectories modifiable and compounded over time
• Importance of early years of life
Source: Halfon N, Conway PH. The Opportunities and Challenges of a Lifelong Health System. NEJM 2013 Apr 25; 368, 17: 1569-1571
Financial Instruments and models that might incentivize lifelong health management
• Horizontally integrated health, education, and social services that promote health in all policies, places, and daily activities
• Consumer incentives (value-based insurance design)• “Warranties”
on specific services• Bundled payment for suite of services over longer period• Measuring health outcomes and rewarding plans for improvement in
health over time• Community health investments• ACOs could evolve toward community accountable health systems
that have a greater stake in long-term population health outcomes
What can you do?
• Eliminate patient harm• Engage patients and families in transformation• Teach others and continuously learn• Test new ideas• Strive to be the best possible quality improvement
infrastructure• Relentless pursuit of improving health outcomes• You are a Major Force for Delivery System Transformation
that continues to increase in importance over time
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Contact Information
Dr. Patrick Conway, M.D., M.Sc.CMS Chief Medical Officer
Director, Center for Clinical Standards and QualityActing Director, Center for Medicare and Medicaid Innovation
410-786-6841 [email protected]
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Questions and Comments
• How can we work together to accelerate the pace of improvement in the health system?
• How can CMS support your efforts?
• How can we drive improvement in all settings and shift towards payment based on value and accountable, coordinated care?
• How do we scale and spread success?
• How can we work together to reduce and attempt to eliminate patient harm in all settings?
• How can we best lead transformation of the delivery system?
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